Travel Request Form

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Name*

Date of Birth*

Date of Birth

Address*

City*

State

Zip Code

Phone Number*

Email Address*

Case Number

Court Status*

Probation Officer *

Request to Travel*

Out-of state

Within state

Departure*

Departure

Departure

Return*

Return

Return

Travel purpose (include name/ place of destination): *

Destination address: *

City*

State*

Zip Code

Accompanied by: Name/ Phone number

Acknowledgement:

I understand that I am to continue to follow the rules of my probation and I am to cooperate with Lake County Juvenile Probation while on this trip. I also understand that this travel permit is not valid until an approval signature has been provided.

Digital Signature

By entering my name below, I accept and agree with the above terms of my travel.